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8. Foot and Ankle MCQs

Practice Set 154 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 3061

Topic: 8. Foot and Ankle

A 35-year-old man injures his midfoot. Radiographs show a small bony avulsion fragment in the space between the base of the first and second metatarsals (the 'fleck sign'). The Lisfranc ligament, which is injured in this scenario, connects which two osseous structures?

. Base of the 1st metatarsal to the base of the 2nd metatarsal
. Base of the 2nd metatarsal to the medial cuneiform
. Base of the 2nd metatarsal to the middle cuneiform
. Medial cuneiform to the middle cuneiform
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Base of the 2nd metatarsal to the middle cuneiform

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no direct interosseous ligamentous connection between the bases of the first and second metatarsals. The 'fleck sign' represents an avulsion of the Lisfranc ligament typically from the base of the 2nd metatarsal.

Question 3062

Topic: Forefoot

A 55-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 17 degrees. Clinical examination reveals no first tarsometatarsal (TMT) hypermobility and no evidence of midfoot arthritis. Which of the following procedures is most appropriate for correcting this deformity?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy with a distal soft tissue release
. Lapidus procedure (first TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal metatarsal osteotomy with a distal soft tissue release

Explanation

The patient has a severe hallux valgus deformity (HVA >30, IMA >13). A distal chevron osteotomy cannot provide sufficient translation to correct an IMA of 17 degrees. A proximal osteotomy (e.g., Ludloff, crescentic, or proximal chevron) combined with a distal soft tissue procedure is required for this magnitude of deformity. A Lapidus procedure is also an option but is strictly indicated when TMT hypermobility or arthritis is present.

Question 3063

Topic: Forefoot

A 45-year-old female presents with painful hallux valgus. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 38 degrees and an Intermetatarsal Angle (IMA) of 16 degrees. The first tarsometatarsal (TMT) joint shows no hypermobility and no signs of arthritis. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal first metatarsal osteotomy (e.g., crescentic or Ludloff) with distal soft tissue procedure
. Akin osteotomy alone
. First tarsometatarsal arthrodesis (Lapidus procedure)
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal first metatarsal osteotomy (e.g., crescentic or Ludloff) with distal soft tissue procedure

Explanation

An IMA greater than 15 degrees signifies a severe deformity that generally cannot be fully corrected with a distal osteotomy alone (like a Chevron). A proximal osteotomy (crescentic, Ludloff, or Scarf) is indicated for larger IM angles. A Lapidus (TMT fusion) is typically indicated when there is concurrent first TMT hypermobility or osteoarthritis, which is absent in this patient.

Question 3064

Topic: 8. Foot and Ankle

Recent high-level randomized controlled trials comparing operative and non-operative management of acute Achilles tendon ruptures, specifically when utilizing early functional rehabilitation protocols, demonstrate which of the following outcomes?

. Operative treatment has a significantly lower re-rupture rate compared to non-operative treatment.
. Non-operative treatment leads to a higher rate of deep vein thrombosis.
. Re-rupture rates are statistically similar between groups, but operative treatment has a higher rate of other complications (e.g., infection).
. Operative treatment provides significantly greater final plantarflexion strength at 1 year.
. Non-operative treatment requires a significantly longer period of strict cast immobilization.

Correct Answer & Explanation

. Re-rupture rates are statistically similar between groups, but operative treatment has a higher rate of other complications (e.g., infection).

Explanation

Recent high-quality RCTs (e.g., Willits et al.) have shown that when early functional rehabilitation (early weight-bearing and ROM in a brace) is employed, the re-rupture rates between operative and non-operative management of acute Achilles ruptures are similar. However, operative management carries higher risks of surgical complications such as wound infections and nerve injuries.

Question 3065

Topic: 8. Foot and Ankle

A 55-year-old patient with poorly controlled type 2 diabetes presents with a red, hot, swollen right foot. Radiographs reveal fragmentation, periarticular debris, and subluxation of the tarsometatarsal joints. There are no open wounds or signs of systemic infection. According to the Eichenholtz classification, what is the best initial management for this stage of Charcot arthropathy?

. Primary arthrodesis of the midfoot
. Total contact casting and non-weight bearing
. Achilles tendon lengthening and an Ankle-Foot Orthosis (AFO)
. Surgical excision of bony prominences
. Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is presenting with Eichenholtz Stage I (Developmental/Fragmentation stage) Charcot arthropathy. The gold standard for initial management is immobilization with a total contact cast (TCC) and strict non-weight bearing to halt the progression of deformity and allow progression to the coalescence stage.

Question 3066

Topic: 8. Foot and Ankle
A 32-year-old male falls from a height and sustains a vertical fracture through the neck of the talus. Radiographs demonstrate that the talar body is subluxated from the subtalar joint, but remains anatomically aligned within the ankle mortise. According to the Hawkins classification, this fracture is categorized as:
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

Hawkins Type II talar neck fractures involve a displaced fracture of the talar neck with subluxation or dislocation of the subtalar joint, while the tibiotalar (ankle) joint remains intact. Type III involves both subtalar and tibiotalar dislocation. Type IV involves subtalar, tibiotalar, and talonavicular dislocation.

Question 3067

Topic: Forefoot

A 40-year-old female presents with a painful bunion. Weight-bearing radiographs show a Hallux Valgus Angle (HVA) of 38 degrees and an Intermetatarsal Angle (IMA) of 16 degrees. Clinical examination reveals gross hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Akin osteotomy of the proximal phalanx
. First tarsometatarsal arthrodesis (Lapidus procedure)
. Keller resection arthroplasty
. Scarf osteotomy

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (arthrodesis of the first TMT joint) is the treatment of choice for moderate to severe hallux valgus (IMA > 13 degrees) complicated by hypermobility of the first TMT joint. It corrects the deformity at the apex of the instability.

Question 3068

Topic: 8. Foot and Ankle
A 55-year-old woman presents with medial ankle pain and a progressively flattening arch. On examination, she has a flexible flatfoot deformity and cannot perform a single-limb heel rise on the affected side. According to the Johnson and Strom classification, what is her stage and optimal treatment?
. Stage I - Tenosynovectomy
. Stage II - Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Stage III - FDL transfer and lateral column lengthening
. Stage III - Triple arthrodesis
. Stage IV - Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Stage II - Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy

Explanation

The patient has a flexible flatfoot (Stage II PTTD) with an inability to perform a single-leg heel rise. Stage I has pain without deformity. Stage III is a rigid deformity requiring arthrodesis. Stage II is typically treated with an FDL transfer to the navicular and a medializing calcaneal osteotomy.

Question 3069

Topic: 8. Foot and Ankle

A 55-year-old male with poorly controlled type 2 diabetes mellitus presents with a swollen, erythematous, and warm right foot. Radiographs show periarticular fragmentation, subluxation of the tarsometatarsal joints, and debris. Which Eichenholtz stage does this represent, and what is the most appropriate initial management?

. Stage 0; surgical arthrodesis
. Stage 1; total contact casting and non-weight bearing
. Stage 2; custom orthotic shoe wear
. Stage 3; surgical debridement and exostectomy
. Stage 1; immediate internal fixation

Correct Answer & Explanation

. Stage 1; total contact casting and non-weight bearing

Explanation

The patient is in Eichenholtz Stage 1 (Developmental/Fragmentation stage), characterized by erythema, swelling, warmth, joint laxity, subluxation, and radiographic evidence of osteopenia, fragmentation, and debris. The gold standard initial treatment is immobilization and off-loading with a total contact cast (TCC) to halt progression and prevent deformity.

Question 3070

Topic: 8. Foot and Ankle

When comparing functional rehabilitation (early mobilization) protocols for non-operative management of acute Achilles tendon ruptures to surgical repair, large randomized controlled trials (such as the Willits trial) have demonstrated which of the following?

. A significantly lower re-rupture rate with surgical repair
. A significantly higher re-rupture rate with non-operative management
. Equivalent re-rupture rates but better plantar flexion strength in the operative group
. Equivalent re-rupture rates and functional outcomes between both groups
. Significant increase in deep vein thrombosis in the operative group

Correct Answer & Explanation

. Equivalent re-rupture rates and functional outcomes between both groups

Explanation

High-quality randomized controlled trials (e.g., Willits et al., JBJS 2010) have shown that when acute Achilles tendon ruptures are treated with early functional rehabilitation protocols (early weight-bearing and early range of motion in a functional orthosis), there is no clinically important difference in re-rupture rates or long-term functional outcomes compared to operative repair, while avoiding surgical risks such as infection or sural nerve injury.

Question 3071

Topic: 8. Foot and Ankle

A 12-year-old boy presents with a rigid flatfoot and recurrent ankle sprains. Radiographs show the 'anteater nose' sign on the lateral view. Which type of tarsal coalition is most likely present, and what is the best initial non-operative treatment?

. Talocalcaneal coalition; orthotics and physical therapy
. Talocalcaneal coalition; short leg cast immobilization
. Calcaneonavicular coalition; short leg cast immobilization
. Calcaneonavicular coalition; cortisone injection
. Cubonavicular coalition; observation

Correct Answer & Explanation

. Calcaneonavicular coalition; short leg cast immobilization

Explanation

The 'anteater nose' sign on a lateral foot radiograph is pathognomonic for a calcaneonavicular coalition, representing the elongated anterior process of the calcaneus approaching the navicular. Initial non-operative management for a symptomatic, painful tarsal coalition typically involves a period of immobilization in a short leg cast (4-6 weeks) to decrease inflammation and joint irritability.

Question 3072

Topic: 8. Foot and Ankle

The Lisfranc ligament is a crucial primary stabilizer of the midfoot. Which of the following accurately describes its anatomic origin and insertion?

. From the medial cuneiform to the base of the second metatarsal
. From the medial cuneiform to the base of the first metatarsal
. From the intermediate cuneiform to the base of the second metatarsal
. From the lateral cuneiform to the base of the third metatarsal
. From the navicular to the base of the second metatarsal

Correct Answer & Explanation

. From the medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is the strongest interosseous ligament in the tarsometatarsal joint complex. It originates from the lateral aspect of the medial cuneiform and courses obliquely to insert onto the medial aspect of the base of the second metatarsal. Notably, there is no direct intermetatarsal ligament connecting the bases of the first and second metatarsals.

Question 3073

Topic: 8. Foot and Ankle

A 30-year-old athlete sustains a severe, primarily ligamentous Lisfranc injury. The surgeon plans a classic primary arthrodesis. To optimize functional outcome and gait biomechanics, which tarsometatarsal (TMT) joints should be included in the formal fusion while deliberately sparing the others?

. 1st and 2nd TMT joints only
. 1st, 2nd, and 3rd TMT joints
. All five TMT joints
. Naviculocuneiform and TMT joints
. 4th and 5th TMT joints only

Correct Answer & Explanation

. 1st, 2nd, and 3rd TMT joints

Explanation

The classic primary arthrodesis for a severe Lisfranc injury involves fusing the rigid medial and middle columns (1st, 2nd, and 3rd TMT joints). The lateral column (4th and 5th TMT joints) is highly mobile and essential for foot accommodation during gait on uneven surfaces; thus, it should be spared and treated with temporary pinning if unstable, rather than rigid fusion.

Question 3074

Topic: 8. Foot and Ankle
A 55-year-old diabetic patient presents with a profoundly swollen, warm, and erythematous left foot, mimicking cellulitis. Radiographs reveal marked osteopenia, subchondral fragmentation, and periarticular bone debris without overt signs of consolidation. According to the Eichenholtz classification for Charcot neuroarthropathy, what stage does this represent?
. Stage 0 (Prodromal)
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation/Remodeling)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

Eichenholtz Stage I is the Development or Fragmentation phase, characterized clinically by a red, hot, swollen foot and radiographically by osteopenia, articular fragmentation, subluxation/dislocation, and periarticular debris. Stage 0 has a normal radiograph; Stage II shows coalescence (absorption of fine debris, early fusion); Stage III is consolidation and remodeling.

Question 3075

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player presents with midfoot pain after another player fell on his heel while his foot was plantarflexed. Physical examination reveals plantar ecchymosis. Weight-bearing radiographs demonstrate 2 mm of widening between the 1st and 2nd metatarsal bases. Anatomically, the native Lisfranc ligament connects which of the following two structures?

. Medial cuneiform to the base of the 1st metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Middle cuneiform to the base of the 2nd metatarsal
. Lateral cuneiform to the base of the 3rd metatarsal
. Cuboid to the base of the 4th metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the 2nd metatarsal

Explanation

The Lisfranc ligament is a critical, stout interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It provides primary stability to the tarsometatarsal joint complex. There is notably no direct ligamentous connection between the bases of the first and second metatarsals, making this interval vulnerable to disruption.

Question 3076

Topic: 8. Foot and Ankle
A 28-year-old male construction worker falls from a ladder and sustains a displaced fracture of the talar neck. Radiographs demonstrate dislocation of both the subtalar and tibiotalar joints. According to the Hawkins classification, what is the approximate expected rate of avascular necrosis (AVN) of the talar body for this specific injury?
. 0-10%
. 20-40%
. 40-50%
. 80-100%
. It depends solely on the time to reduction

Correct Answer & Explanation

. 80-100%

Explanation

This injury is a Hawkins Type III talar neck fracture, defined by displacement of the talar neck with dislocation of both the subtalar and tibiotalar joints. Because the three main sources of retrograde blood supply to the talar body (artery of the tarsal canal, deltoid branches, and artery of the sinus tarsi) are sequentially disrupted, the risk of AVN is exceptionally high, approaching 80-100%.

Question 3077

Topic: 8. Foot and Ankle

A 42-year-old weekend warrior sustains an acute Achilles tendon rupture 4 cm proximal to the calcaneal insertion. This area is notoriously hypovascular and often referred to as the 'watershed area' of the Achilles tendon. Which artery provides the predominant vascular supply to this specific watershed region?

. Anterior tibial artery
. Peroneal artery
. Posterior tibial artery
. Sural artery
. Lateral plantar artery

Correct Answer & Explanation

. Peroneal artery

Explanation

The vascular supply to the Achilles tendon is derived from the posterior tibial and peroneal arteries. However, the classical 'watershed' hypovascular zone, located 2 to 6 cm proximal to the calcaneal insertion, is supplied primarily by small, relatively sparse branches of the peroneal artery. This precarious blood supply makes this zone highly susceptible to degenerative changes and subsequent mechanical rupture.

Question 3078

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes mellitus presents with a deformed, non-tender midfoot. Radiographs reveal coalescing bone fragments, absorption of fine bone debris, and early fusion of large fragments. According to the Eichenholtz classification of Charcot arthropathy, what stage is currently demonstrated?

. Stage 0 (High risk/Inflammation)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction/Consolidation)
. Stage 4 (Remodeling)

Correct Answer & Explanation

. Stage 2 (Coalescence)

Explanation

Eichenholtz Stage 1 involves active fragmentation, joint dislocation, and fine debris. Stage 2 (Coalescence) is marked by the absorption of fine debris, early fusion, and sclerosis of large fragments. Stage 3 (Consolidation) shows remodeling and rounding of bone ends.

Question 3079

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a severe hyperdorsiflexion injury to the ankle. Radiographs reveal a displaced talar neck fracture with subluxation of the subtalar joint. The tibiotalar and talonavicular joints remain congruent. According to the Hawkins classification, what is the stage of this injury and its approximate associated risk of avascular necrosis (AVN)?
. Hawkins I, 0-10% AVN
. Hawkins II, 20-50% AVN
. Hawkins III, 80-100% AVN
. Hawkins IV, 100% AVN
. Hawkins II, 90-100% AVN

Correct Answer & Explanation

. Hawkins III, 80-100% AVN

Explanation

Hawkins classification for talar neck fractures: Type I = non-displaced (0-10% AVN). Type II = displaced with subtalar subluxation/dislocation (20-50% AVN). Type III = displaced with subtalar and tibiotalar dislocation (~80-100% AVN). Type IV = displaced with subtalar, tibiotalar, and talonavicular dislocation (~100% AVN).

Question 3080

Topic: 8. Foot and Ankle

Which of the following ligaments provides the primary stabilization to the Lisfranc joint complex?

. Plantar ligament connecting the medial cuneiform to the base of the second metatarsal
. Dorsal ligament connecting the medial cuneiform to the base of the second metatarsal
. Interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal
. Plantar ligament connecting the lateral cuneiform to the base of the third metatarsal
. Interosseous ligament connecting the first and second metatarsal bases

Correct Answer & Explanation

. Interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal

Explanation

The Lisfranc ligament is the interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the strongest and most important stabilizer of the tarsometatarsal articulation. There is no direct transverse ligamentous connection between the bases of the first and second metatarsals.

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